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Journal of Prevention & Intervention in


the Community
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Urban African American Youth Exposed


to Community Violence: A School-Based
Anxiety Preventive Intervention Efficacy
Study
a b a c
Michele R. Cooley-Strickland , Robert S. Griffin , Dana Darney
a a
, Katherine Otte & Jean Ko
a
Department of Mental Health, Johns Hopkins Bloomberg School of
Public Health, Baltimore, Maryland, USA
b
Center for Culture and Health, Department of Psychiatry, NPI-
Semel Institute for Neuroscience, University of California–Los
Angeles, Los Angeles, California, USA
c
Department of Educational, School & Counseling Psychology,
University of Missouri, Columbia, Missouri, USA
Version of record first published: 08 Apr 2011.

To cite this article: Michele R. Cooley-Strickland , Robert S. Griffin , Dana Darney , Katherine
Otte & Jean Ko (2011): Urban African American Youth Exposed to Community Violence: A School-
Based Anxiety Preventive Intervention Efficacy Study, Journal of Prevention & Intervention in the
Community, 39:2, 149-166

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Journal of Prevention & Intervention in the Community, 39:149–166, 2011
Copyright # Taylor & Francis Group, LLC
ISSN: 1085-2352 print=1540-7330 online
DOI: 10.1080/10852352.2011.556573

Urban African American Youth Exposed to


Community Violence: A School-Based Anxiety
Preventive Intervention Efficacy Study

MICHELE R. COOLEY-STRICKLAND
Department of Mental Health, Johns Hopkins Bloomberg School of Public Health,
Baltimore, Maryland, and the Center for Culture and Health, Department of Psychiatry,
NPI-Semel Institute for Neuroscience, University of California–Los Angeles,
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Los Angeles, California, USA

ROBERT S. GRIFFIN
Department of Mental Health, Johns Hopkins Bloomberg School of Public Health,
Baltimore, Maryland, USA

DANA DARNEY
Department of Educational, School & Counseling Psychology, University of Missouri,
Columbia, Missouri, USA

KATHERINE OTTE and JEAN KO


Department of Mental Health, Johns Hopkins Bloomberg School of Public Health,
Baltimore, Maryland, USA

This study evaluated the efficacy of a school-based anxiety preven-


tion program among urban children exposed to community viol-
ence. Students who attended Title 1 public elementary schools
were screened. Ninety-eight 3rd–5th-grade students (ages 8–12;
48% female; 92% African American) were randomized into pre-
ventive intervention versus waitlist comparison groups. Students
attended 13 biweekly one-hour group sessions of a modified
version of FRIENDS, a cognitive-behavioral anxiety intervention

This research was supported by grants from the National Institute of Mental Health (PI:
Cooley; R21 MH63143) and the National Institute on Drug Abuse (PI: Cooley; R01 DA018318).
We extend our gratitude to the Baltimore City Public School System and the principals,
teachers, parents, caregivers, and students who participated in the FRIENDS Program.
Address correspondence to Michele R. Cooley-Strickland, Department of Psychiatry,
NPI-Semel Institute for Neuroscience, University of California–Los Angeles, Center for Culture
and Health, 760 Westwood Plaza, Box 62, B7437, Los Angeles, CA 90024-1759, USA. E-mail:
mcooley@mednet.ucla.edu

149
150 M. R. Cooley-Strickland et al.

program. Results indicated that both intervention and control


groups manifested significant reductions in anxiety symptoma-
tology and total exposure to community violence, along with
improved standardized reading achievement scores. Additional
gains observed only in the intervention group were increased stan-
dardized mathematics achievement scores, decreased life stressors,
and reduced victimization by community violence. The inter-
vention was equally efficacious for both genders and for children
exposed to higher, compared to lower, levels of community viol-
ence. Implications for comprehensive, culturally and contextually
relevant prevention programs and research are discussed.

KEYWORDS African American, anxiety, children and youth,


community violence, ethnic minority, prevention, school-based
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interventions

Community violence in schools, neighborhoods, and communities is a major


public health problem (WHO, 2002). Children’s exposure by hearing about,
witnessing, and=or experiencing it reached critical levels decades ago and
there it remains. The effects of exposure to community violence may pro-
foundly affect children’s development in multiple domains from early child-
hood into adolescence and beyond (Cooley-Strickland et al., 2009). For
example, studies have found a positive association between community viol-
ence exposure and anxiety (Cooley-Quille, Boyd, Frantz, & Walsch, 2001;
Ward, Martin, Theron, & Distiller, 2007) and that anxiety interferes with
children’s ability to concentrate, thus potentially disrupting their academic
performance (Birmaher et al., 2004). It has been recommended that develop-
mentally appropriate interventions for children exposed to community viol-
ence are implemented early and are evaluated for their effectiveness
(Berkowitz, 2003). This article reports on the effects of a secondary preven-
tive intervention program to investigate its impact on community violence,
anxiety, and related functioning (academic achievement, life stressors)
among urban ethnic minority school children.
Community violence affects all racial and ethnic groups, but African
Americans living in low-income urban neighborhoods experience higher
rates of community violence and crime than urban European Americans
(Crouch, Hanson, Saunders, Kilpatrick, & Resnick, 2000). Exposure to viol-
ence among African American youth does not decrease with higher socio-
economic status, as it does for European Americans (Crouch et al., 2000).
Constant worry about one’s own or loved ones’ safety or health likely
interferes with low income, urban children’s ability to function in develop-
mentally appropriate, academically successful, and healthy ways (Cooley-
Quille, Boyd, & Grados, 2004) and may be a source of anxiety and
Prevention Among Community Violence Exposed Youth 151

oppositional-aggressive behavior as an attempt to exert control in chaotic


environments (Ford, 2002). Low income, urban youth have elevated anxiety
disorder symptoms (Rathus, Wetzler, & Asnis, 1995). Those living in perpetu-
ally violent communities may be in a constant state of defense, potentially at
risk for developing anxiety symptoms as a result of a neurological structure
that is ready to deal with external threats at any time (Edlynn,
Gaylord-Harden, Richards, & Miller, 2008). This is consistent with the con-
cept of Allostatic load identified by McEwen (2000) as referring to the physio-
logical costs of chronic exposure to the neural stress response.
Anxiety disorders in childhood and adolescence are serious mental
health problems (Barrett & Turner, 2001) which occur at disturbingly high
rates (Barrett, Farrell, Ollendick, & Dadds, 2006). They are the most fre-
quently experienced mental health disorder among children and adolescents
and are experienced by about 13 out of every 100 children from ages 9 to 17
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years, with approximately half of them suffering from an additional mental


health disorder (DHHS, 1999). Left untreated, children with anxiety disorders
are at significant risk for developing other psychological disorders (e.g., Cole,
Peeke, Martin, Truglio, & Seroczynski, 1998; Last, Hansen, & Franco, 1997) as
well as problems such as poor social skills, low self esteem, and substance
abuse (DHHS, 1999). Anxiety symptoms and disorders in childhood may
interfere with children’s long-term academic functioning, as those affected
by an anxiety disorder are significantly less likely to be in school or working
in young adulthood (Last et al., 1997). African Americans are less likely than
European Americans to receive appropriate treatment for anxiety problems
(Young, Klap, Sherbourne, & Wells, 2001).
School-based treatment and preventive interventions are needed for
youth exposed to chronic community violence (Cooley-Strickland et al.,
2009). A review of them was conducted by Cooley and Lambert (2006).
Providing interventions in schools improves attendance at sessions, reduces
stigma associated with therapy (Stallard, Simpson, Anderson, Hibbert, &
Osborn, 2007), and delivers the services in communities where resources
may be sparse. There are well-evaluated school-based intervention programs
designed to treat anxiety (Stallard et al., 2007). Studies have demonstrated that
cognitive-behavioral treatment (CBT) is effective for reducing childhood anxi-
ety (Barrett, Duffy, Dadds, & Rapee, 2001; Kendall, 1994) and group-based
CBT has proven to be effective for treating childhood anxiety (e.g., Shortt,
Barrett, & Fox, 2001). Although there is very little research on CBT with
diverse populations (Bryant & Harder, 2008) it has proven to be effective
for Latino=Hispanic (Kataoka et al., 2003) and African American students in
school-based settings (Ginsburg & Drake, 2002). Yet to be tested in a rando-
mized control study is a group CBT anxiety preventive intervention program
with urban African American children exposed to community violence.
FRIENDS (Barrett, Webster, & Turner, 2000) is a group CBT program
designed originally as a treatment program for Australian children with
152 M. R. Cooley-Strickland et al.

anxiety disorders. It has been established as a successful school-based group


anxiety prevention program in Australia (Barrett & Turner, 2001;
Lowry-Webster, Barrett, & Dadds, 2001) and in the United States with
majority students (i.e., 97% European American; Bernstein, Layne, Egan, &
Tennison, 2005). FRIENDS uses the core CBT components (exposure, relax-
ation, cognitive strategies, contingency management) and targets the primary
components of anxiety (physiological, cognitive, behavioral). A distinctive
element of the current project is that it applies this effective intervention to
underserved ethnic minority youth who live in neighborhoods with low
resources and high levels of external threats.
The aim of the current study was to reduce the symptoms and prevent
the onset of severe anxiety disorders among African American children
exposed to community violence who attend urban public elementary
schools. The primary hypothesis was that compared to the non-intervention
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comparison youth, participants in the modified FRIENDS program would


have fewer anxiety symptoms at post-intervention. It was also expected that
FRIENDS would be equally efficacious for males and females, and for chil-
dren exposed to high and low levels of community violence. Secondarily,
it was expected that children in the intervention group would experience
less community violence exposure and related adverse life events as a result
of improved cognitive, physiological, and behavioral skills. Relatedly, it
was expected that academic achievement may improve for intervention
participants.

METHOD

Participants
Participants (N ¼ 93) were African American (92%) and biracial (8%) students
8 to 12 years old (grades 3–5; 48% female), in two Title 1 public elementary
schools located in Baltimore, MD. Both schools were located in economically
disadvantaged urban communities (average of 90% of the student bodies
received free or reduced lunch) characterized by high crime.

Intervention
FRIENDS (Barrett & Turner, 2001; Barrett et al., 2000) is a group-oriented
CBT selected anxiety prevention program that targets students with mild to
moderate anxiety disorders. The cognitive, physiological, and behavioral
components of the FRIENDS Program teach children specific strategies for
coping with anxiety, including problem-solving skills and skills to cope with
fearful stimuli. During the sessions didactic lessons were taught by the group
leaders, then students participated in activities and role-plays to practice the
new skills. Students were given weekly homework assignments to help
Prevention Among Community Violence Exposed Youth 153

generalize the skills they learned to the classroom and home environments.
Examples of session content include: identifying physiological symptoms of
anxiety (e.g., students were taught to identify emotions and body cues),
learning relaxation techniques (e.g., deep breathing and visualization), and
engaging in positive feelings, thoughts, and self-talk as they actively face
challenges and fears.
FRIENDS is an acronym for the skills it teaches, which stands for: F—
Feeling worried?; R—Relax and feel good; I—Inner thoughts; E—Explore
plans; N—Nice work so reward yourself; D—Don’t forget to practice; and
S—Stay calm, you know how to cope now (Shortt et al., 2001). The current
preventive intervention program was based on the FRIENDS Program
(Barrett, Lowry-Webster, & Holmes, 1999), albeit modified to be culturally
and contextually appropriate for ethnically diverse urban American children,
particularly African Americans. The guiding principle of this adaptation was
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to limit changes to shallow structure modifications that facilitated the stu-


dents being able to comprehend and relate to the program content, while
striving to maintain the therapeutic integrity of the cognitive-behavioral inter-
vention. For example, the relaxation exercises were modified from animals
that were indigenous to Australia (e.g., koalas, bilbys, cattle dogs, crocodiles)
to those found in urban America (e.g., pigeons, mice, dogs, kittens); CDs
were made of the relaxation exercises for the students to take home and
practice. Children drew pictures of real-life violence that had occurred in
their communities that they had either heard about happening, witnessed,
or had personally been victimized by. Other opportunities to relate incidents
and anxiety associated with living in violent and chaotic environments (e.g.,
fights, gangs, drugs, low resources) were integrated into the sessions; further
cultural and contextual modifications for the intervention may be found in
Cooley-Quille et al. (2004).
Under the supervision of a licensed psychologist (the first author), the
group leaders and co-leaders received training and supervision in the
FRIENDS preventive intervention (e.g., review of the intervention curriculum
and materials, role-plays, practice sessions). The FRIENDS Program consisted
of 13 biweekly, one-hour sessions led by a doctoral-level African American
group leader and African American or European American co-leader with at
least a bachelor’s degree. Sessions were implemented as a pull-out program
during the school day in small groups of 8–10 students. Make-up sessions
were held for children who missed their regular session. Including the
make-ups, all participants attended at least 12 of the 13 sessions.
Because family factors are commonly associated with the development
and maintenance of childhood anxiety (Barrett, 1998) and family involve-
ment in treatment helps reduce anxiety in children (Bernstein et al., 2005),
the current project planned 3 one-hour parent sessions using the FRIENDS
parent manual. The sessions were based on CBT, reviewed child manage-
ment skills, skills the children were acquiring in the FRIENDS program,
154 M. R. Cooley-Strickland et al.

and how to encourage them in their children to promote generalizability to


the home and larger community. Instead, a single expanded parent session
was held; fewer than half of the families attended.

Measures
Exposure to community violence was assessed using the Children’s Report of
Exposure to Violence (CREV; Cooley, Turner, & Beidel, 1995). The CREV is a
widely used self-report questionnaire developed to assess children’s lifetime
exposure to community violence. It has good two-week test–retest reliability
(r ¼ .75), internal consistency (overall a ¼ .78), and construct validity (Cooley
et al., 1995). Twenty-nine scored CREV items are rated on a 5-point Likert
scale, ranging from 0—‘‘no, never’’ to 4—‘‘everyday,’’ to indicate the fre-
quency of exposure to community violence via four modes (i.e., media, hear-
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say, witness, victimization). Types of violent situations include being chased


or threatened, beaten up, robbed or mugged, shot, stabbed, or killed. Higher
scores indicate more perceived exposure. A past-year version of the CREV
was developed and administered at the post-assessment evaluation.
Cronbach’s a for the lifetime CREV Total score was .88 at baseline and .90
for the past-year version.
Mental health was assessed using the Computerized Diagnostic
Interview Schedule for Children. It is a comprehensive, structured interview
that covers mental health disorders for children and adolescents using
DSM–IV criteria (Shaffer, Fisher, Lucas, Dulcan, & Schwab-Stone, 2000).
Eighteen modules were administered at baseline, including the anxiety,
depression, attention=hyperactivity, and conduct modules. Eight anxiety
modules were administered during the post assessment. The C-DISC has
demonstrated excellent interrater reliability with 97% of clinicians agreeing
with the C-DISC’s diagnosis (Wolfe, Toro, & McCaskill, 1999).
Anxiety symptomatology was assessed using the Revised Children’s
Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1997), a self-report
measure of the level and nature of anxiety in children and adolescents. It
is a 37-item questionnaire in which students agree or disagree to statements
pertaining to how some people think or feel about themselves, assessing dif-
ferent ways anxiety is manifested. A higher score indicates more anxiety and
distress. The RCMAS has good internal consistency (a ¼ 0.83) and test-retest
reliability (r ¼ 0.68). In the FRIENDS study, Total RCMAS reliability was
a ¼ 0.83 at baseline and a ¼ 0.84 at post-assessment.
Academic achievement was assessed using the Wechsler Individual
Achievement Test–Screener (WIAT–Screener; Psychological Corporation,
1992), which consists of three subtests of the comprehensive WIAT battery
(i.e., Basic Reading, Mathematics Reasoning, Spelling). It assesses basic aca-
demic skills; permits the calculation of age- and grade-based standard scores;
was standardized using a large representative sample; is widely used; and has
Prevention Among Community Violence Exposed Youth 155

demonstrated reliability and validity with little evidence of practice effects


(Psychological Corporation, 1992).
Adverse life events were assessed using the Multicultural Events Schedule
for Adolescents (MESA; Gonzales, Gunnoe, Samaniego, & Jackson, 1995),
developed to assess major and minor life events specific to an urban multi-
ethnic population (Gonzales et al., 1995). It was normed on African American,
European American, and English- and Spanish-speaking Mexican Americans.
The MESA includes 84 items in which a student responds yes or no to each life
events over the past year. A Total life events score is based on the number of
events endorsed, with a higher score indicating more adverse life events and
hassles. The MESA has adequate concurrent validity and test–retest reliability
(Gonzales et al., 1995). In the FRIENDS project, the MESA Total score a ¼ .89
at baseline, and a ¼ .95 at the post-assessment.
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Procedure
BASELINE SCREENING AND SELECTION OF PARTICIPANTS
A two-stage screening process identified children for participation in the
FRIENDS Program. First, parents=guardians of students in the 3rd through
5th grades in regular education or resource classes at the two urban public
elementary schools were mailed letters of notification informing them of
the RCMAS (Reynolds & Richmond, 1978) and CREV (Cooley et al., 1995)
administration at their child’s school with an option to decline participation.
Children who assented and whose parents=caregivers provided permission
were administered the RCMAS and CREV in groups by classroom (12 classes
in two schools; 330 [82%] students were assessed out of 404 in the combined
student body). Teachers in each classroom (n ¼ 16) nominated up to three
very anxious students, following Dadds, Spence, Holland, Barrett, and Lau-
rens (1997) procedure, resulting in 34 students who were automatically con-
sidered for the next level of eligibility in the project. Consistent with other
school based interventions (e.g., Stein et al., 2003), teachers were also asked
to identify up to three children in their classrooms who were extremely dis-
ruptive or aggressive and therefore would not be appropriate for group ses-
sions. Those 51 students were eliminated from the project although their
exclusion did not eliminate all anxious children with co-occurring aggressive
behavior from the FRIENDS program. Children were included and eligible
for further consideration for the FRIENDS program if they: (1) had a CREV
Total score > 10; and (2) either a RCMAS T-score of 51 or higher or were
included in the teachers’ nominations of anxious children. They were
excluded if they were not in regular education or resource classes or had
been nominated by teachers as extremely disruptive.
In the second stage of screening, parents of the 207 eligible students
were asked to provide written consent for their child to participate in a
156 M. R. Cooley-Strickland et al.

comprehensive anxiety assessment battery at school for urban children


exposed to community violence, as well as permit their child to be rando-
mized to an anxiety prevention program or wait-list control condition,
treated (including parent participation in sessions), and participate in the
post-assessment evaluation, if the child was found eligible to participate.
Of those contacted, parental consent was provided by 122 (58.9%) of them;
their children were administered a comprehensive, multi-method assessment
battery including the: WIAT Screener, MESA, and C-DISC. Assessments were
conducted by trained research assistants in empty classrooms for the
90-minute battery. Incentives to encourage participation were given to tea-
chers (e.g., class pizza party for classrooms with 80% or higher response
rates), parents (e.g., $40 lottery), and students (e.g., dictionaries, pencils).
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FINAL SELECTION AND RANDOMIZATION


Parents were given feedback about their child’s status. Eligible children who
were considered ‘‘at-risk’’ for anxiety disorders and who endorsed at least
mild exposure to community violence were invited to participate in the
FRIENDS selected prevention program to be randomized to preventive inter-
vention or wait-list control conditions. To be considered ‘‘at-risk,’’ the child
had to have a mild to moderate DSM–IV anxiety diagnosis or features=symp-
toms of an anxiety disorder. Twenty-six students were excluded from the
project for: currently receiving mental health treatment for an anxiety dis-
order; a threshold level DSM–IV disruptive behavioral disorder (i.e.,
Attention-Deficit=Hyperactivity Disorder [ADHD], Conduct Disorder, Oppo-
sitional Defiant Disorder [ODD]); too few anxiety symptoms; or a severe
anxiety disorder. Those students were not randomized to conditions and
were excluded from the study; parents were offered referrals for child mental
health services if needed and=or desired. Children who assented following
their parents’ consent (n ¼ 93) were randomly assigned to the intervention
or wait-list comparison group. Post-intervention assessments were conduc-
ted at the end of the FRIENDS program.

RESULTS

Comparison of the intervention (n ¼ 48) and wait-list control (n ¼ 45) groups


using Chi-square and ANOVA tests revealed no significant differences in
demographic characteristics, academic performance, community violence,
anxiety, or adverse life events (Table 1; ps > .05). In comparing the two Title
1 schools from which the participants were recruited, there were no signifi-
cant differences (Chi-square and ANOVA tests; ps > .05) between them on
age of the participants or any of the academic performance or psychosocial
measures. The two schools differed on ethnic composition (Chi-square
Prevention Among Community Violence Exposed Youth 157

TABLE 1 Baseline Characteristics of the FRIENDS Intervention and Control group (N ¼ 93)

Intervention Control
group (n ¼ 48) group (n ¼ 45) Chi-squared
Variables n (%) n (%) (df)

Gender
Males 24 (0.5) 24 (0.53) 0.35 (2)
Females 24 (0.5) 21 (0.47)
Race=Ethnicity
African American 45 (0.94) 40 (0.89) 0.74 (2)
Mixed=Biracial 3 (0.06) 5 (0.11)

Mean (SD) Mean (SD) F-statistic (df)

Age (years) 9.47 (1.16) 9.35 (1.0) 2.419 (2)


CREV total 46.15 (17.86) 49.25 (20.72) 0.91 (2)
RCMAS total 16.71 (4.97) 16.00 (5.86) 1.89 (2)
WIAT Composite- 9.72 (1.60) 9.88 (1.30) 0.68 (2)
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Age Equivalent
MESA total score 17.96 (9.48) 18.57 (9.41) 1.79 (2)

Note. All ps > .05.

(df) ¼ 14.88(1); p < .01) such that the program participants from one school
were 97.7% African American and 2.3% biracial (22.9% of the neighborhood
residents lived below the poverty level), whereas the other were 75.8%
African American and 24.2% biracial (8.6% of neighborhood residents lived
below poverty).

Within-Group Comparisons
Paired t-tests were used to investigate within-group changes on community
violence exposure, academic performance, and psychosocial outcomes
(Table 2). Both groups showed significant reductions in their Total
exposure to community violence at post-intervention compared to baseline
(Table 2; ps < .01). The intervention group also experienced a mean
reduction in community violence victimization; the control group did not
(p > .05). Significant reductions in overall anxiety, as measured by total
RCMAS score, were observed in both groups at post-intervention from base-
line (ps < .01). Reading performance significantly improved from baseline to
post-intervention in both groups (WIAT Reading age equivalent; ps < .05).
The FRIENDS intervention group’s mathematics performance score also sig-
nificantly improved, although the control group’s did not. The intervention
group was performing mathematical skills at the mean equivalent of a
9.6-year-old (SD ¼ 1.9) at baseline, and the equivalent of a 10-year-old
(SD ¼ 1.8) at post-intervention (p < .01). The intervention, but not control,
group had significant reductions in adverse life events, as measured by
the Total MESA score (p < .01).
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TABLE 2 Within Group Baseline and Post-Intervention Differences (N ¼ 93)

Intervention (n ¼ 48) Control (n ¼ 45)

Baseline Post-intervention Pre=post paired Baseline Post-intervention Pre=post paired


Measure mean (SD) mean (SD) mean difference (SD) mean (SD) mean (SD) mean difference (SD)

CREV total 33.7 (13.4) 19.4 (14.0) 14.3 (17.3) 36.0 (18.1) 25.6 (15.9) 10.4 (16.7)
CREV victimization 1.8 (2.1) 0.6 (1.2) 1.1 (1.9) 1.7 (1.6) 1.0 (1.7) 0.6 (2.3)

158
RCMAS total 17.1 (4.7) 12.1 (6.5) 5.0 (6.7) 15.8 (5.3) 10.9 (4.7) 5.0 (5.9)
WIAT Reading 9.5 (1.4) 10.2 (1.9) 0.7 (0.9) 9.9 (1.4) 10.3 (1.7) 0.4 (0.8)
(Age equivalent)
WIAT Math 9.6 (1.9) 10.0 (1.8) 0.4 (0.9) 9.7 (1.3) 9.8 (1.1) 0.2 (0.6)
(Age equivalent)
MESA total 17.4 (9.2) 12.7 (12.4) 4.7 (9.5) 18.6 (9.6) 14.8 (11.4) 3.9 (12.3)

Note. p < .01.
Prevention Among Community Violence Exposed Youth 159

Between-Group Comparisons
A two-group repeated measures MANOVA, controlling for baseline mea-
sures, was conducted to investigate the differences across baseline and
post-intervention for the FRIENDS intervention versus control group. The
two groups did not significantly differ on the major variables of interest
(CREV, RCMAS, WIAT, MASC, behavior change, program likeability; no
group by time interactions were found; ps > .05; data not shown). A time
effect was observed, as the entire sample had lower levels of anxiety
(RCMAS; F(1,71) ¼ 10.139; p < .01) and improved scores on age-based WIAT
Reading performance (F(1,70) ¼ 5.26; p < .05).

Gender Differences at Post-Intervention


A 2  2 Factorial ANOVA controlling for baseline measurements was conduc-
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ted to investigate whether the FRIENDS intervention was equally efficacious


for male (n ¼ 24) and female (n ¼ 24) participants. There were no significant
main effects for intervention status on any of the measures of interest
(ps > .05; data not shown).

Post-Intervention Differences for High and Low Exposure to


Community Violence
A two-group repeated measures MANOVA, controlling for baseline mea-
sures, was conducted to investigate whether the FRIENDS intervention was
equally efficacious for individuals who reported high and low exposure to
community violence at baseline. The median CREV score at baseline was
used to classify high and low community violence exposure (CVE) groups.
As expected, the two exposure groups did not differ significantly on academ-
ic performance or measures of anxiety (ps > .05; data not shown).

DISCUSSION

Anxiety disorders are based in part on unrealistic appraisals of threat. How-


ever, children who have been exposed to high levels of chronic community
violence may face danger that is not unrealistic—such as threats of physical
harm or safety—that may adversely affect their physiological and cognitive
well-being. Participants in the FRIENDS program gave many examples of
the real-life dangers they faced as residents in violent communities.
Research on assessing youth’s threat appraisals in response to community
violence has recently been published (Kliewer & Sullivan, 2008) based
on the recognized need of accurately understanding the unique threats
posed by this form of life stressor. Questions arise such as: When are fears,
worries, and apprehension among youth exposed to community violence
160 M. R. Cooley-Strickland et al.

psycho-pathological? Are the fears protective? At what point should anxiety


be targeted for intervention? Ideally, economic and environmental changes
at the community level would occur that removed the threats to urban chil-
dren like poverty, guns, street drugs, and gangs. Until then, intervening at
the individual, school, and family levels may benefit youth, including tar-
geting unhealthy levels of distress and anxiety. Certain levels of anxiety
protect against African American youth’s exposure to community violence
(Boyd, Cooley, Lambert, & Ialongo, 2003; Lambert, Ialongo, Boyd, &
Cooley, 2005), although studies of the ‘‘optimal’’ level among this popu-
lation are warranted.
Anxiety can negatively influence cognitive as well as social develop-
ment (Cooley-Quille et al., 2001). The FRIENDS Program did not specifically
target academic skills but its participants exhibited improved standardized
reading and mathematics achievement scores whereas the control children
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only showed improved reading. Perhaps math skills improved as a result


of the intervention’s focus on problem-solving and other cognitive compo-
nents, although this study was not designed to identify which specific ele-
ments caused which intervention effects. Regardless, there were notable
developmental benefits of the intervention, particularly given substantial
pressure on students and schools to perform at least at grade level because
of local, state, and national performance-based initiatives.
Controlling for baseline scores, children who participated in the
FRIENDS intervention group showed reduced levels of victimization of com-
munity violence and fewer life stressors, whereas the control group did not.
Perhaps this is related to the skills taught in the intervention and emphasis on
strategies for coping with anxiety (e.g., relaxation techniques, engaging in
positive feelings, thoughts, and self-talk as they actively face challenges
and fears). Additionally, students in the intervention group were taught to
attend to perceived external threats and to problem-solve. Homework
assignments were administered to help the children to generalize the skills
they learned to their natural environments. Perhaps the children in the inter-
vention group learned to manage life stressors and make healthier life deci-
sions, including regarding those that placed them at-risk for exposure to and
victimization by community violence.
In the FRIENDS parent session, the FRIENDS leader encouraged
parents=caregivers to observe their children and be available to hear and
help process their children’s concerns and stresses. Multiple caregivers indi-
cated difficulty in doing so because they felt overly stressed themselves (e.g.,
working more than one job; caring for multiple children, grandchildren, and=
or great-grandchildren; severe economic challenges; and=or limited
resources). Previous studies have found some added benefits of family anxi-
ety management training or parent management training in interventions
with anxious youth (Barrett et al., 2001; Bernstein et al., 2005). In future inter-
ventions with community violence exposed youth, a comprehensive parental
Prevention Among Community Violence Exposed Youth 161

intervention may be warranted, although sufficient resources should be allo-


cated to address the challenges to participation.
Teaching urban, primarily African American children with greater life
stressors, fewer resources and social supports (Myers & Taylor, 1998) to
reward themselves, to talk to their friends about their problems, and make
friends in order to build social support networks (i.e., ‘‘traditional’’ concep-
tualizations of developing positive peer relationships)—as the FRIENDS
Program is designed to do—may be problematic without ample consider-
ation of the cultural milieu. For example, peer relations among urban ethnic
minority youth may be adversely complicated by concerns of appearing
‘‘weak’’ (e.g., fearful, nervous, emotionally needy) because perceived weak-
ness may make inner-city residents more vulnerable to violence victimiza-
tion. Enhanced coping skills and social support have helped reduce the
effects of community violence exposure on African American youth (Edlynn
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et al., 2008; Hammack et al., 2004), although programs designed to teach


these capacities should include methods to identify and elicit rewarding
sources of prosocial support.

Limitations
One limitation of the current study is frequently found in school- and
community-based research projects involving ethnic minority participants:
Low parental consent rates. Students are prevented from reaping potential
benefits of school-based mental health programs if their parents do not
consent to their participation (Stein et al., 2007). Parental permission and
child assent rates obtained during the first stage of screening were accept-
able (82%), but parental consent was only in the low-moderate range
(59%) in the second stage despite active recruitment strategies. The most
effective mechanism for parental cooperation was linked to building the
school community’s trust over time and enhancing the parent’s relationship
and comfort with the school. Nonetheless, as a result of the relatively small
and highly selected sample, the study’s power and generalizability are
restricted.
There were exceptions (WIAT Screener, C-DISC) but the majority of out-
come measures reported in this study are self-report questionnaires. Data
from additional informants at pre- and post-intervention would have
strengthened this investigation, as would behavioral measures of the efficacy
of the FRIENDS intervention (e.g., psychophysiological, neurobehavioral
assessments). The study was designed to obtain both teacher and parent
reports. The former was obtained as part of the screening procedure (i.e.,
teacher nominations), but neither was obtained for the outcome measures.
The original approach of sending parental report forms home for parents=
caregivers to complete proved to be inadequate and was discontinued.
Future studies should allocate sufficient resources to obtain outcome data
162 M. R. Cooley-Strickland et al.

from multiple informants (e.g., in-person or telephone interviews, sufficient


incentives, adequate tracking procedures).
The results of the current study indicated significant decreases in
self-reported anxiety for both the intervention and control groups in the
within-group comparisons. However, the assessments were conducted
immediately following treatment, as the end of the school year had arrived,
and there were no significant between-group differences. A longer follow-up
may have yielded differential results for the two groups. Some other child
anxiety preventive intervention studies have not observed significant
improvements until a substantial amount of time has passed and the children
have been able to implement, practice, and generalize the skills that they
have learned. For example, Dadds and colleagues (1997) did not find signifi-
cant differences in anxiety reduction among children who participated in the
anxiety intervention compared to controls immediately following treatment,
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but the intervention group maintained their treatment gains over 6 and
24 months whereas the control group did not. Another study did not find sig-
nificant changes in children’s self-reported anxiety in an efficacy study of the
FRIENDS intervention, although parental reports indicated significantly
decreased anxiety among children who participated in the intervention com-
pared to the controls (Bernstein et al., 2005), suggesting the importance of
involving parents as informants in studies involving anxious children.
The current study lacked a clearly delineated comparison group, which
also may have contributed to the failure to find between-group differences,
yet there were within-group differences. The FRIENDS Team was given a
classroom in the school where both intervention and control group students
completed their assessment batteries and were welcomed to visit (i.e., get
snacks, draw, chat). FRIENDS staff became active and integrated members
of the school community (e.g., attended school events, Back-to-School Night,
PTA meetings, talent shows, basketball games). Control students reported
liking being ‘‘members of the FRIENDS Team’’ as much as the intervention
participants. Some reported the FRIENDS program was the only organized
‘‘team’’ to which they belonged, a reflection of the under-resourced environ-
ments in which they lived. The unanticipated impact of this relationship may
have attenuated distinctions between the intervention and control groups, at
least in the short-term and may speak to the power of creating community
and meaningful relationships beyond the proscribed intervention.

Future Studies
It is well established that African American youth are less likely than
European Americans to receive appropriate treatment for anxiety problems
(Young, Klap, Sherbourne, & Wells, 2001). After school programs may be
ideal venues for time- and resource-intensive interventions because they pro-
vide the security and resources of the school setting, community accessibility,
Prevention Among Community Violence Exposed Youth 163

and reduced costs and stigma associated with clinical settings. The FRIENDS
Program was implemented in only 13 contact hours with the students, yet
resulted in significant gains for this underserved population. It speaks to
the need to continue to develop comprehensive, multi-component preven-
tive intervention efforts that target not only anxiety, but also developmen-
tally, ecologically, culturally and contextually appropriate factors within a
community environment. Future studies designed to prevent the adverse
effects of youth’s exposure to stressful community violence should involve
larger sample sizes, longer-term follow-ups, more comprehensive preventive
intervention programs, and comprehensive multi-informant assessments of
cognitive, neuropsychological, behavioral, academic, and=or social out-
comes, not just those constructs directly related to anxiety. Understanding
developmental timing and optimal dosage levels are also important.
Cost-effectiveness studies are needed, as preventive and treatment interven-
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tions conducted in school-based settings may have particular cost-efficiency


over the long term. Intervening with urban African American youth who have
been chronically exposed to community violence even using a brief, focused
intervention resulted in within-group improvements in emotional, beha-
vioral, and academic well-being.

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